ACS issues a 'wake-up call' on double-booked surgeries

'It's not clear how these guidelines would change the status quo,' senator says

The American College of Surgeons (ACS) on Wednesday released new guidelinesindicating that providers should inform patients in advance if their surgeons are scheduled to perform overlapping surgeries, Jenn Abelson and Jonathan Saltzman report for the Boston Globe.

Background on the issue

Overlapping surgeries —in which an attending surgeon is responsible for multiple surgeries in multiple ORs at the same time for at least a portion of the procedures—are a fairly common practice and are permitted at many teaching hospitals.

Proponents say that such "double-booking" allows hospitals to reduce wait times and have their most in-demand surgeons do more procedures, particularly during daytime hours. Teaching hospitals can use the practice to give residents graduated responsibility for components of surgeries. And in some instances, such as in trauma care, proponents say overlapping surgeries can be necessary to care for clusters of emergency and urgent cases.

However, the practice has come under scrutiny since the Boston Globe reported that little scientific research has been done on concurrent surgeries, and that "there is no consensus among top doctors about which procedures can safely overlap, and how much overlap is appropriate."

Opponents of the practice have two main concerns:

Multiple surgeries overseen by the same attending that overlap for extended periods of time, as opposed to cases that only have short overlaps at the beginning and end of surgeries; and

Insufficient patient consent about overlapping surgeries.

The U.S. Senate Finance Committee last month requested several years of concurrent surgery records from 20 hospitals and health systems.

New recommendations

The new ACS guidelines say overlapping surgeries are generally permissible but call for tighter governance of the practice. For instance, ACS says attending surgeons need to inform patients if they plan to participate in overlapping operations. The guidelines also state that concurrent surgeries—which ACS defines as "when the critical or key components of the procedures for which the primary attending surgeon is responsible are occurring all or in part at the same time"—on multiple patients in multiple ORs are "not appropriate."

In instances when the "critical or key" elements of one operation have been finished and "there is no reasonable expectation" that the primary attending surgeon will need to return to the operation, ACS says a surgeon can delegate less critical parts of an operation to another surgeon while he or she begins an operation in another room. ACS notes that such "overlapping operations" shouldn't "negatively impact the seamless and timely flow of either procedure."

ACS guidelines are not legally binding, but they have "enormous" influence on surgeons, the Globe reports.

A wake-up call

The new guidelines generally mirror Medicare's billing regulations.

L.D. Britt, a former ACS president who served on the committee that drafted the new guidelines,says the new standards will serve "as a wake-up call to the surgeons" and increase the likelihood that patients are informed of concurrent surgeries ahead of time.

But some critics say the ACS guidelines still give too much discretion to surgeons—for example, in determining what counts as a "critical" part of an operation. James Rickert, an Indiana surgeon who is president of the Society for Patient Centered Orthopedics, contends that "the guidelines are inadequate," adding, "They simply codify and defend the status quo regarding concurrent surgery."

Sen. Chuck Grassley (R-Iowa), who has led efforts in Congress to rein in concurrent surgeries in the wake of the Globe investigation, also says the new ACS guidelines fall short. "It's not clear how these guidelines would change the status quo reported by the Boston Globe," he says(Abelson/Saltzman, Boston Globe, 4/13).

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